10 Gaps in Original Medicare Coverage You Should Know

The gaps in Original Medicare coverage may cost you thousands if you are uninformed about what’s not covered by Part A and Part B and don’t have coverage for all the benefits you may need.

If you are enrolled in the Medicare program, you probably already know that Medicare doesn’t cover everything. Original Medicare, Part A and Part B, does cover many hospital and medical benefits, such as inpatient hospital stays, durable medical equipment, and preventative services. However, it only begins to cover all the health needs required by the older and disabled individuals enrolled in this program.

That is why many opt to enroll in or keep other types of coverage to help cover the gaps in Original Medicare coverage. This includes employer retiree programs and Medicare private health insurance plans, such as Medicare Advantage, Part D, and Supplement plans.

10 Gaps in Original Medicare Coverage

While there are several benefits not covered by Medicare, here are 10 of the most common and important gaps in Medicare coverage that you should be aware of:

1. 20% of the costs of Part B covered expenses

Medicare Part B covers medically necessary doctor’s services, outpatient care, and other medical services and supplies. However, with the exception of most preventive services, you will be charged 20% of Medicare-approved amount for all covered expenses. This is in addition to the annual deductible and monthly premiums that must be paid before Part B coverage begins.

Plans that may fill this gap: Medicare Supplement plans

2. Part B excess charge

If your doctor, provider, or supplier does not accept Medicare assignment, this means that they will not accept the Medicare-approved amount as full payment. In addition to the 20% of costs you are responsible for already, this means that you could additionally be charged an excess charge of up to 15% for Part B covered services.

Plans that may fill this gap: Medicare Supplement plans

3. Prescription drug coverage

Original Medicare comes with limited prescription drug coverage. This includes oral anti-cancer drugs, injections received in a doctor’s office, drugs used with certain types of durable medical equipment, and other very limited drugs received in a hospital outpatient setting. Generally, all other medication coverage must be obtained through a Medicare Part D plan, unless you have another type of coverage already. If you are enrolled in Medicare and go 63 or more days in a row without creditable drug coverage, you may be charged a late enrollment penalty.

Plans that may fill this gap: Medicare Part D plans, which include Medicare Prescription Drug Plans and Medicare Advantage Prescription Drug plans

4. Vision benefits

Medicare Part A and Part B coverage only includes medically necessary vision benefits, such as glaucoma tests if you are at high risk, cataract surgery, eyeglasses with standard frames (or contacts) after cataract surgery. However, it will not pay for routine eye exams and many other vision benefits.

Plans that may fill this gap: Medicare Advantage plans

5. Dental benefits

Similarly, most dental benefits are not considered to be medically necessary. This includes routine exams, cleanings, fillings, dentures, and braces. Original Medicare will only cover dental procedures in limited situations, such as having a jaw disease and needing surgery before you can undergo radiation treatment.

Plans that may fill this gap: Medicare Advantage plans

6. Hearing benefits

Part B will only cover hearing exams if your health care provider orders them to see if you require medical treatment. This may be the case if you have had hearing loss as a result of an illness or injury. Routine hearing exams and hearing aids are not covered by Part A and Part B.

Plans that may fill this gap: Medicare Advantage plans

7. Long-term care

The Medicare program and most health insurance plans will not cover long-term care, also known as custodial care, which is non-medical care for individuals with chronic illnesses or disabilities.

Plans that may fill this gap: No Medicare plans, but there are other long-term care insurance options

8. Acupuncture

Neither Part A nor Part B will cover any acupuncture services and other types of alternative therapies, even if it is provided by a health professional whose other services are typically covered by Medicare.

Plans that may fill this gap: Medicare Advantage plans

9. Foreign travel emergency coverage

Medicare generally only covers medical care within the United States, which includes the 50 states, the District of Columbia, and other U.S. territories. It will not cover any medical care received outside of the country, except in very limited circumstances. This may include care received on a cruise ship while the ship is in U.S. territorial waters and care received in a foreign hospital if it is closer to your residence than the nearest available U.S. hospital.

Plans that may fill this gap: Medicare Supplement plans

10. Other Part A and Part B out-of-pocket costs

As mentioned earlier, there are also several out-of-pocket costs, such as deductibles, coinsurance, and copayments that must be paid before Medicare will begin paying for its share of covered services and supplies. In addition to the Part B copayment and excess charge, there are deductibles that must be paid for Part A and Part B before coverage begins. Part A coverage requires a copayment or coinsurance for hospital, hospice, and skilled nursing facility care. Additionally, depending on whether you or your spouse paid Medicare taxes while working, you may have to pay a monthly premium for Part A, in addition to the Part B premium.

Plans that may fill this gap: Medicare Supplement plans

Are you enrolled in Part A and/or Part B? How have you chosen to fill in coverage gaps?

As a contributor and editor of the PlanPrescriber Blog, Angela Chen has extensive knowledge about the Medicare program and the various associated private insurance products, including Medicare Advantage, Medicare Part D, and Medicare Supplement (Medigap) plans. Her areas of interest include health and wellness, marketing, journalism, and social media.

Part B excess charge – actually, although 15% is the “limiting charge”, non-participating physicians are penalized 5% of the participating physician Medicare reimbursement rate. The excess charge limit then is 15% of 95% of the reimbursement rate, or 9.25% above the participating approved amounts for services. Beneficiaries should be informed that being billed for Part B excess charges is a nominal risk at best. Fewer that 4% of all physicians do not participate in Medicare, and many non-participating physicians actually do take assignment from Medicare on cases and will not bill Part B excess. Another disincentive to the physician is that it the non-participating physician refuses assignment, Medicare pays the claim directly to the beneficiary, and the physician has to collect the full amount directly from the beneficiary – which adds both admin expense and loss potential.

Thanks for this information. It’s not readily available in the government website, nor as easily explained. I would like to make a copy of this page for my own records, in case this blog disappears. May I? It will not be republished; just tucked onto a Word Document. Thank you.

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I had Medicaid and now I am going to fight it. I am on lou income something is wrong. what is the best plan I can take now. medicare. I do not see doctors that much my drugs I lou. I hope is stay that way,.Eileen thank you